AORN, ACS Spar on Head Coverings in the OR

The skullcap: should it stay or should it go?

Two professional societies are going head-to-head on the issue of appropriate attire in the operating room, specifically on the matter of skullcaps.

The Association of periOperative Registered Nurses (AORN) and the American College of Surgeons (ACS) have released dueling statements about appropriate head coverings in surgical suites, with the former group arguing that it's time to retire one of the trademark symbols of their craft while the latter defends it.

AORN fired the first salvo earlier this year updated guidelines on OR attire, which stated that "personnel entering the semi-restricted and restricted areas should cover the head, hair, ears, and facial hair."

That was followed this month by guidelines on proper attire from the surgeons' group, which included a statement that "the skullcap is symbolic of the surgical profession" and should be retained, even though it does not provide the same coverage recommended by AORN.

"The skullcap can be worn when close to the totality of hair is covered by it and only a limited amount of hair on the nape of the neck or a modest sideburn remains uncovered. Like OR scrubs, cloth skull caps should be cleaned and changed daily. Paper skull caps should be disposed of daily and following every dirty or contaminated case. Religious beliefs regarding headwear should be respected without compromising patient safety," read the ACS statement, released on Aug. 4.

AORN fired back last week: "Head coverings based on symbolism and a personal attachment to historical norms have no place in the patient benefits analysis expected of guidelines developers," read a statement on AORN's website posted Aug. 16.

"Any guidance for care should be based on a systematic review of the evidence and an analysis of benefits balanced with harms to patients," Lisa Spruce, DNP, RN, director of Evidence-Based Perioperative Practice at AORN, told MedPage Today.

"Perioperative professionals have a duty to their patients to minimize the risk of exposure to potentially pathogenic organisms present in the hair and skin of human beings that could lead to a surgical site infection," said Spruce. "The benefit of covering the head, ears, and hair is the reduction of the patient's exposure."

"We do not say how to accomplish this," she continued. "If a skullcap covers all of the head, hair, and ears, then it can be worn."

Contacted by MedPage Today for a response, an ACS representative had no comment beyond referring to the Aug. 4 statement.

One surgeon belonging to ACS, John Magaña Morton, MD, MPH, chief of bariatric and minimally invasive surgery at Stanford School of Medicine, told MedPage Today that he plans to continue to wear skullcaps: "It's amazing to me that this has even risen to this level," he said.

He noted that an evidence base for AORN's recommendation appeared to be lacking (AORN itself admitted that it was indirect at best), and he suggested that surgical bonnets worn over the ears could be detrimental to patient safety.

"It's a big concern to me that [it] would cover the ears," said Morton. "We need to be able to communicate in the operating room, and that is not sufficient for safety."

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